stimulation is required, then to this last combination one to three
drachms each of tincture of cantharides and tincture of capsicum may be
added. Liquid applications may be made as follows: An eye-dropper is
filled and introduced between the hairs at different points of the
scalp, and a few drops pressed out, and subsequently rubbed in by means
of a piece of flannel rag; in this manner the application is brought
into intimate association with the skin without to any extent soiling
the hair.
Ointments are also useful. Sulphur, one or two drachms to the ounce, is
one of the best. Ammoniated mercury, twenty to sixty grains to the
ounce, red precipitate, five to twenty grains to the ounce, are both
valuable. In some cases tannic acid, one or two drachms to the ounce,
acts well; also a naphthol ointment, twenty or thirty grains to the
ounce. Tar is also of decided value, and may be added to any of the
above ointments or be prescribed alone in ointment, one or two drachms
to the ounce. The tarry oils, as oil of white birch and oil of cade,
used pure or in the form of tincture, one or two drachms to the ounce
of alcohol, are also valuable. They may also be used with ointments.
The treatment of seborrhoea of other parts of the body than the scalp
is essentially the same, but the applications should be somewhat
weaker. The sulphur preparations are the most useful.
The frequency of applications in seborrhoea will depend upon the
activity of the process. Once or twice daily in the beginning may
gradually be changed to once every other day, or later even less
frequently. The soap-and-water washing is to be regulated in the same
manner. It is advisable to intermit external treatment occasionally to
see if the disease is entirely removed or merely in abeyance.
Comedo.
Comedo is a disorder of the sebaceous glands, consisting of retention
of sebaceous matter, characterized by yellowish or blackish
pinpoint- to pinhead-sized elevations corresponding to the orifices of
the glands. The affection is seated, for the most part, about the face,
neck, and upper part {590} of the trunk; it may occur, however,
wherever there are sebaceous glands. Each lesion is pinpoint to pinhead
in size, whitish or yellowish, and usually with a central blackish
point. There is very little elevation unless the amount of retained
sebaceous matter is excessive. They may exist sparsely or in great
numbers. Not infrequently the regions of the forehead, nose, and chin
are studded with the lesions, other parts of the face and the shoulders
showing them in smaller numbers. They may be disseminated or grouped.
If they exist in profusion they give the face a soiled, greasy look, as
if dirty and unwashed. Lateral pressure forces out the sebaceous matter
in a thread-like form closely resembling a worm, hence the popular
terms flesh-worms and grub-worms. From collection of dust and from
other causes the outer ends of the sebaceous plugs become blackened,
and this appearance has given rise to the term black-heads. This
coloring may possibly, to some extent at least, as has been suggested,
be dependent upon a chemical change caused by the action of the air on
the exposed portion of the sebaceous collection. According to Unna, it
is due to pigment matter, either free or contained within epidermal
cells. Krause states that the bluish granules described by Unna are
from extraneous sources. Seborrhoea oleosa is often seen to coexist. At
times the retained secretion, either as a result of pressure or in
consequence of chemical changes in the mass, excites inflammation, and
acne results. It is not uncommon to find comedones and acne lesions
associated together.
The affection is seen most frequently between the ages of fifteen and
thirty. The lesions are sluggish, and are apt to disappear and reappear
from time to time, depending upon the activity of the predisposing
cause. As the patient advances in age the affection tends to
spontaneous disappearance. The causes of the disorder are essentially
the same as give rise to acne, a disease to which it is, as may be
inferred, closely allied. Thus, disorders of digestion, constipation,
chlorosis, scrofulous conditions and menstrual disturbances are often
predisposing causes. In addition, the unstriped muscular fibres of the
skin lack tone and contract sluggishly. The infrequent use of soap,
especially in those with oily skins (seborrhoea oleosa), favors their
formation. Working in a dirty or dusty atmosphere may cause mechanical
obstruction of the ducts, and in consequence the formation of
comedones.
Pathologically, the affection has its seat in the sebaceous glands and
ducts, consisting essentially of retained secretion and epithelial
cells within either the gland or duct or both. The accumulation gives
rise to more or less dilatation, which usually increases the longer the
comedo exists. The mass consists of epidermic cells, sebaceous matter,
and sometimes cholesterin crystals, and one or more lanugo hairs. At
times, also, the parasite Demodex folliculorum is found within the
mass, but is not responsible in any way for the production of the
lesion; it is also often found in healthy follicles. The dark points
which usually mark the lesions are due to the accumulation of dirt. The
process is an inactive one, occasioning usually no disturbance. The
accumulation may increase until a papule is formed, or, on the other
hand, may gradually relieve itself. The affection is to be
distinguished from acne punctata and milium. Acne is a closely-allied
disease, but is inflammatory in its nature; comedo is functional in
character: the presence or absence of {591} inflammation, therefore, is
a decisive differential point between the two diseases. Milium differs
from comedo in the facts that it has no open duct, no black point, and
the contents cannot be squeezed out.
The result of treatment is usually favorable, several months sufficing
for its removal. On the other hand, occasionally cases are met with
which prove rebellious. The aim of constitutional treatment should be
to remove the predisposing condition. For this purpose cod-liver oil,
iron, quinine, arsenic, and various other tonics, and ergot in full
doses, are variously prescribed. At times, small doses (about a tenth
to a fourth of a grain) of calx sulphurata have a good effect. Saline
aperients are often valuable. An aperient tonic pill of iron, aloes,
and strychnia is sometimes serviceable. Open-air exercise and other
hygienic measures are to be advised.
External treatment is of great importance,--is in fact indispensable.
The condition may in many cases be relieved by local applications
alone. Removal of the plugs by mechanical means is to be advised.
Lateral pressure with the finger-ends, or perpendicular pressure with a
watch-key or similar instrument, will be found effectual. Washing the
parts with sapo viridis and hot water, with considerable friction and a
kneading motion, will aid in dislodging the sebaceous collections.
Instead of the sapo viridis its solution in alcohol, two parts of the
soap to one of alcohol (spiritus saponatus kalinus), may be employed.
Steaming the face or the application of hot water from ten to twenty
minutes will aid in softening the secretion, and with friction and
kneading will often have a good effect. Friction with sand soap is also
valuable. A soap made of equal parts of green soap (sapo viridis) and
finely-pulverized marble may also be used. The use of the dermal
curette is at times of service, scraping off the tops of the comedones,
rendering their expulsion more easy. After the soap-washing and
hot-water application ointments or lotions containing sulphur, such as
prescribed in acne, may be applied. The following lotion is often
valuable:
Rx. Sulphuris præcipitati, drachm ij;
Ætheris, fluidounce ss;
Alcoholis, fluidounce iijss. M.
S. Shake before using: dab on with a mop for several minutes, allowing
it to dry on.
Alkaline lotions containing borax or sodium bicarbonate, ten to twenty
grains to the ounce, are often useful. The following paste has been
highly spoken of for loosening and dislodging the sebaceous plugs:
Rx. Aceti, drachm ij;
Glycerinæ, drachm iij;
Kaolini, drachm iv. M.
S. Apply over the surface at night. If applied near the eyes, the lids
should be kept closed for a few moments, on account of the pungent
fumes of the vinegar. The lotion containing zinc sulphate and potassium
sulphide, the formula of which is given in the treatment of acne, is of
value. Corrosive-sublimate lotions, one-half to two grains to the
ounce, are useful in some cases. In changing from a sulphur to a
mercurial application, treatment should be suspended for several days,
so that the formation of the black sulphuret of mercury, which may
darken the skin and comedo plugs to an annoying degree, may be {592}
avoided. If treatment brings about considerable irritation of the
parts, a result often desirable, it should be omitted temporarily and
soothing applications made.
Milium.
Milium, described also as grutum and strophulus albidus, consists in
the formation of small, whitish, roundish, pearly, non-inflammatory
elevations situated in the upper part of the corium. The lesions are
usually pinhead in size, whitish or yellowish, seemingly more or less
translucent, rounded or acuminated, without aperture or duct, and
appear for the most part about the face, especially about the eyelids,
and occasionally elsewhere. One, several, or great numbers may be
present; ordinarily, however, but several are to be seen, usually near
the eyes. In our experience the affection is observed most frequently
in middle-aged women. The lesions develop slowly, and after a certain
size is reached may remain stationary for years. Their presence causes
no disturbance, and unless large and numerous the affection is but
slightly noticeable. Acne and comedo are often found associated with
it. The cutaneous calculi occasionally met with are milia which have
undergone calcareous metamorphosis. The etiology of the disease, in a
great majority of cases, is not known. In some cases, however, the same
causes as are operative in the production of comedo and acne seem to
have an influence.
Anatomically, the affection is found to have its seat in the sebaceous
glands. The duct from some cause is obliterated and the secretion
cannot escape. The retained mass consists of sebaceous matter which
tends to become inspissated and calcareous, and, as the lesion is
without aperture, it cannot be squeezed out. The epidermis constitutes
the external covering. It has also been shown by several authorities
that the covering proper is either the gland itself or the wall of the
hair-follicle, and that in the larger lesions connective-tissue septa
are found. According to the investigations of Robinson, two different
conditions have been described as milia--one which evidently has its
origin in the sebaceous glands or ducts, and the other in which there
is no connection whatever with these structures. The lesions are
characteristic and the diagnosis easy. The absence of the duct-opening
and black point of comedo serves to distinguish it from that disease.
The small lesions of xanthoma--a disease which usually has its seat
about the eyelids--may resemble it, but can scarcely be confounded with
it, as its nature is entirely different.
As regards treatment, it is usually necessary in all cases to incise
the lesions and squeeze out or scrape out their contents; in some,
touching the base of the excavation with a minute drop of iodine
tincture or nitrate of silver may be required to prevent a
reappearance. Electrolysis has also been recommended.
Steatoma.
Steatoma--or, as commonly called, sebaceous cyst, sebaceous tumor, or
wen--appears as a variously-sized, elevated, roundish, or semi-globular
firm or soft tumor having its seat in the corium or subcutaneous
tissue. {593} One or several may be present. They are cysts of the
sebaceous glands, and may exist wherever these structures occur, but
are seen most frequently about the scalp, face, back, and scrotum. They
develop slowly, are variable as to size, and may exist indefinitely
without causing any inconvenience except disfigurement. The overlying
skin is either normal in color or whitish from stretching; on the scalp
it is usually devoid of hair. Cysts are usually firm, but may be doughy
or soft. As a rule, they are freely movable and painless. In some a
gland-duct orifice can be seen; in the majority it is absent.
Spontaneous suppuration and ulceration may occasionally take place in
enormously distended tumors. Anatomically, steatoma is a cyst of the
sebaceous gland and duct, produced by retention of secretion. It is in
fact an enormously distended duct and gland whose walls have become
thickened into a tough sac. The contents vary, in some being hard and
friable, in others soft and cheesy or even fluid, with or without a
fetid odor, and of a grayish, whitish or yellowish color. The mass
consists of fat-drops, epidermic cells, cholesterin, and sometimes
hairs. As a rule, the diagnosis is made without difficulty. Gummata,
which may have some resemblance, grow more rapidly, are usually painful
to the touch, are not freely movable, and tend to break down and
ulcerate. Sebaceous cysts can scarcely be mistaken for fatty tumors and
osteomata.
In the treatment excision is radical and most satisfactory. A linear
incision is made, and the mass and enveloping sac dissected out. A
removal of the sac is necessary, or a reproduction usually takes place.
As the scalp wound especially should be treated on antiseptic
principles, injecting the tumor with a small quantity of tincture of
iodine or other irritant has been successfully employed.
CLASS II.--INFLAMMATIONS.
Erythema Simplex.
Erythema simplex is a hyperæmic disorder characterized by redness,
occurring in the form of variously sized and shaped, diffused or
circumscribed, non-elevated patches. The affection is due to various
causes, which may be external or internal. Hence it is usual to divide
the affection into two classes--idiopathic and symptomatic. Under the
head of idiopathic erythema are described the erythemas due to cold,
heat, traumatism, poison, etc. Erythema caloricum arises from the
action of heat or cold. If the degree of heat or cold is sufficient, a
dermatitis, or even gangrene, may result. In a mild degree, however,
simple congestion of the skin--erythema--is produced. It is usually
bright red in color, later becoming somewhat darker, and at times is
followed by slight desquamation. If produced by the action of the
sun--erythema solare--the uncovered parts only are affected. Erythema
traumaticum is usually seen {594} as a result of the pressure of
tightly-fitting clothes, corsets, bandages, etc. It disappears rapidly
upon removal of the cause, without scaling. If the cause is long
continued, a dermatitis may be produced. Erythema venenatum is a term
applied to the form of hyperæmia resulting from the action of
substances poisonous to the skin: such are all irritating chemicals,
the ordinary rubefacients, various dyestuffs, acids, alkalies, and the
like. The symptomatic erythemas are the more important. The rashes
often preceding or accompanying certain of the systemic diseases, such
as smallpox, diphtheria, and vaccinia, belong to this class. Disorders
of the digestive tract, especially in children, are responsible for
many cases. Roseola is a term sometimes applied to the symptomatic
rashes. The division-line between simple erythema and dermatitis is
often ill-defined.
The indications for treatment in the various erythemata are usually
self-evident. A removal of the cause in idiopathic rashes is all that
is needed. The same may be stated of the symptomatic erythemata; but
here there is at times difficulty in recognizing the etiological
factor. Local treatment is rarely necessary. Dusting-powders, mild
lotions, or ointments such as used in acute eczema may be prescribed.
* * * * *
ERYTHEMA INTERTRIGO.--Erythema intertrigo--known popularly as
chafing--is a hyperæmic disorder occurring on parts where the natural
folds of the skin come in contact, characterized by redness and at
times an abraded surface and maceration of the epidermis. The causes
are usually local. Thus it appears chiefly about the folds of the neck
in fat subjects, the nates, groin, perineum, and axillæ. It is seen
usually in hot weather in infants and others whose skin is tender. The
skin becomes red from chafing, and if long continued or untreated the
perspiration of the parts causes more or less maceration of the epiderm
and a mucoid discharge. If the condition continues, actual inflammation
may be developed. The affection may pass away in a few days or last
several weeks. There is a feeling of heat and soreness about the
affected parts. Occurring between the nates in infants, a favorite
locality, from the friction of the parts, and the action of the feces
and urine, it is often persistent. As a rule, it yields readily to
treatment. The predisposition to its development, and its continuance
are often due in children to derangement of the stomach or intestinal
canal.
In the treatment undue moisture and friction of the parts are to be
prevented or counteracted. Washing with castile soap and cool water,
and cleanliness, should be advised. The folds or parts are to be
separated or kept apart with lint, cloth, or absorbent cotton.
Dusting-powders are to be used freely, as they constitute the best
method of treatment. The following is a good formula:
Rx. Pulv. zinci oxidi, drachm ij;
Pulv. talci Veneti, drachm ij;
Pulv. amyli, drachm iv. M.
Simple starch and lycopodium powder, alone or together, will both prove
efficacious. If the affection prove rebellious to this plan of
treatment, astringent and alcoholic lotions may be used. Black wash,
diluted, dabbed on the parts several times daily, followed by
oxide-of-zinc ointment or a dusting-powder, will be found useful in
obstinate cases. A weak {595} solution of corrosive sublimate, a
fraction of a grain to the ounce, may also prove valuable in some
instances. Lotions of zinc sulphate or of acetate of lead, two or three
grains to the ounce, and a weak solution of alum, may also be
mentioned. A lotion we have often found of service is the following:
Rx. Pulv. calaminæ,
Pulv. zinci oxidi, aa. drachm iss;
Alcoholis, fluidrachm ij;
Aquæ rosæ, fluidounce iv. M.
Sig. Shake before using. Apply several times daily. The local treatment
of rebellious cases is, in fact, that which is found efficacious in
acute erythematous eczema.
Erythema Multiforme.
Erythema multiforme is an acute inflammatory disease characterized by
reddish, more or less variegated macules, papules, and tubercles,
occurring discretely or in patches of various size and shape. Certain
regions of the body, such as the backs of the hands and feet and the
arms and legs, are the parts mainly invaded. The eruption, as the name
signifies, is usually marked by the multiformity of its lesions,
although, as a rule, one of the forms is generally predominant.
Peculiarities which the lesions assume have given rise to the
qualifying terms annulare, iris, and marginatum, etc. Thus, when the
erythematous patch is circular, fading in the centre, it is called
erythema annulare. At times concentric rings, presenting variegated
colors, are formed, giving rise to the term erythema iris. When the
eruption consists of sharply-defined marginate patches, it is
designated erythema marginatum. Most commonly, the eruption appears in
the form of papules and tubercles. Erythema papulosum is the form of
the disease usually met with. It consists of discrete or aggregated
patches of flat papules, variable as to size and shape. In color they
are bright red, violaceous, or purplish, disappearing partly under
pressure. They fade rapidly, rarely lasting longer than a few weeks.
Erythema tuberculosum is a form of the disease occasionally encountered
in which the lesions are larger, but of the same general character as
in the papular variety.
Erythema multiforme varies as regards duration, averaging about two
weeks. During its course new lesions are apt to develop as the older
eruption fades away. As the lesions disappear slight pigmentation and
desquamation are noticeable. In addition to the parts already named as
commonly invaded, the face is sometimes the seat of the eruption. It
may, moreover, attack the mucous membranes. The subjective symptoms are
rarely marked: usually slight burning and itching are complained of.
There may be evidences of constitutional disturbance, such as malaise,
headache, rheumatic pains, and gastric derangement, especially at the
beginning; as a rule, however, general symptoms are not observed.
Relapses, especially from year to year, are not uncommon. The causes of
the disease are in most cases obscure. It is most frequent in early
adult age. Spring and autumn seem to be predisposing factors, although
it is also seen at other periods of the year. Gastric disturbance may
give {596} rise to the eruption in some instances. Rheumatism is
occasionally associated with it. The affection is more common in the
female.
Anatomically, the affection is an exudative disease, resembling
urticaria. It is generally regarded as a vaso-motor disturbance. It is
closely related to herpes iris and erythema nodosum, and by some these
are looked upon as varieties. In regard to the diagnosis, it is to be
differentiated from urticaria. In the latter affection itching and
burning are prominent and constant symptoms, the lesions are fugacious,
and the duration of the disease shorter. It can scarcely be confounded
with eczema, in which disease the lesions are smaller and intensely
itchy, and the eruption does not assume the different shapes seen in
erythema multiforme. Erythema nodosum and herpes iris are also to be
differentiated. The prognosis is always favorable, as the affection
runs a definite course, usually disappearing at the end of a few weeks.
It is rarely influenced by treatment.
Saline laxatives, alkalies, and the bromides may be given and the diet
regulated. In the beginning of the attack large doses of quinine may be
useful. Locally, applications of alcohol or vinegar and water, or a
lotion of carbolic acid, five or ten grains to the ounce of water, will
be found of advantage if itching or burning is present. As a rule,
active external treatment is not required.
Erythema Nodosum.
Erythema nodosum (syn., dermatitis contusiformis) is an acute
inflammatory affection characterized by the formation of
variously-sized, roundish or ovalish, more or less elevated
erythematous nodes. Febrile disturbance usually ushers in the eruption,
often accompanied with gastric derangement, malaise, and rheumatic
pains. The efflorescence appears rapidly, having special predilection
for the arms and legs, particularly the tibial surfaces. The lesions
vary in size, being rarely smaller than a cherry and often as large as
an egg, and are ovalish or roundish in shape. They are reddish in
color, with a bluish or purplish tinge, which becomes more decided as
they grow older. Later, as they are disappearing, yellowish, greenish,
and bluish coloration manifests itself, as in the case of a bruise. Not
infrequently the lesions are hemorrhagic. When at its height a node has
a shining, tense appearance, indicative apparently of beginning
suppuration; this latter process, however, does not occur, absorption
invariably taking place. Firm and hard at first, as they begin to
decline they become softer. They are apt to appear in crops. The
lesions are rarely present in large numbers, from five to twenty being
the average; occasionally, however, they are much more numerous. The
mucous membranes may, as in erythema multiforme, be invaded. They are
tender and more or less painful, and are usually accompanied with a
sense of burning. Lymphangitis is at times observed. At the end of two
or three weeks the affection has usually run its course.